IREMSC Equipment Request Form

Please verify that all information is correct before sending.

Please see the IREMSC store catalog available on this site for a list of equipment & supplies that are available.

**Please note we only ship within Alaska.

If you place your order less than 48 hours in advance please call Rachel Mulvihill, Material Specialist during her office hours to see if the equipment is available. 

               Ms. Mulvihill's office hours are Monday through Friday 8am to 12pm.                     Phone: 907-456-3978 ●  Fax: 907-456-3970

Just complete this form. Click on Submit when ready to send.
Renter's Name *

First
Last
Renter's Daytime Phone Number *

### 		-
### 		-
####
Renter's Mailing Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Renter's Email *
Is this going to be billed to a separate party from the renter? *
 No 
 Yes 
If yes, please fill out the financially responsible party box.
Financially Responsible Party (Contact name & phone number, if different from renter)
This in no way relieves the renter of the financial responsibility of payment should the billing party not fulfill their obligation. The renter will be responsible for late fees and or damages made to the equipment.
Shipping Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
If the the billing address is different that shipping please put the address in the comments section.
How would you like your order shipped
 Customer will pick up 
 US Mail Service 
 UPS 
 Freight Service-please note that a $30 delivery charge will be billed to deliver your items to the freight office.  
START DATE: What date is the equipment needed? *

MM 		/
DD 		/
YYYY
DUE DATE: The date the equipment will be returned to IREMSC. *

MM 		/
DD 		/
YYYY
Items Needed *
Please include the item ID, the amount you need
Comments and Questions
Rental Agreement Terms *
 I have read the IREMSC Rental Policy and agree to its terms and conditions.  
The IREMSC Rental Policy is at the bottom of the page, clicking the link will open a new window.
Image Verification
captcha
Please enter the text from the image:
[Refresh Image] [What's This?]
Powered byEMF Online Form Builders
Report Abuse

Read the IREMSC Rental Policy